1. Introduction to Impulse-Control Disorders Not Elsewhere Classified

Most people will likely do something impulsive at some point in their lives. However, when a person is unable to resist impulses to act in ways that are harmful to themselves or others, it may be a considered an impulse-control disorder. Currently, five impulse-control disorders are identified in the DSM-IV-TR: intermittent explosive disorder, kleptomania, pathological gambling, pyromania, and trichotillomania.

2. Intermittent Explosive Disorder (312.34)

Intermittent explosive disorder, also known as IED, is characterized by the failure to resist aggressive impulses, which result in serious assaults or property destruction (American Psychological Association, 2000). The degree of aggression displayed during these outbursts is grossly out of proportion with the events that provoke them. (Bayer, 2000). The short-lived episodes of aggression provide a way for the person with IED to vent his or her anger and frustration (Bayer, 2000). These verbal or physical outbursts are much more intense than normal anger, and the individual with IED is unable to control them (Bayer, 2000). The aggression the individual feels is often ego-dystonic, so they may feel regret or guilt after committing the aggressive act (Bayer, 2000; Blankenship, 2008). IED is not the same as aggression that is purposeful and premeditated, and it does not arise out of personal motives, such as revenge, social dominance, or monetary gain (Blankenship, 2008).

History of IED:

The name of this disorder has changed over time and so has the diagnostic criteria listed in the DSM. In the DSM-I, IED was called passive aggressive personality, aggressive type; in the DSM-II, it was renamed explosive personality disorder.

The term intermittent explosive disorder was first used in the DSM-III, and the diagnostic criteria excluded individuals with antisocial personality disorder and generalized aggression or impulsivity (Blankenship, 2008).

In the DSM-III-R, individuals with borderline personality disorder were also excluded (Blankenship, 2008).

The current diagnostic criteria for IED no longer excludes generalized aggression or impulsivity (Blankenship, 2008).

For an individual to be diagnosed with IED, the outbursts cannot be triggered by other disorders or medication. However, people with IED very likely to abuse drugs (Bayer, 2000).

IED and suicide:

A study assessing the prevalence rates of suicidal and self-injurous behavior among individuals with IED found that approximately 17% of patients exhibited self-aggressive behavior, 12.5% had attempted suicide, and 7.4% had performed non-suicidal, self-injurous behavior (McCloskey, Ben-Zeev, Lee & Coccaro, 2008).

It was also found that women were at an increased risk for self-injurous behavior overall (McCloskey et al., 2008).

Furthermore, individuals with major depressive disorder were found to be at a higher risk of self-aggressive behaviors, including suicide attempts (McCloskey et al., 2008).

DSM-IV-TR criteria

A. Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property.

B. The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors.

Some individuals see their impulses as stressful and destructive before, during, and after they react to these impulses. Episodes may be associated with affective symptoms (racing thoughts, rage, etc.) during the aggressive acts and rapid onset of depressed mood after the acts. Some episodes may be preceded by tingling, tremors, palpitations, chest tightness, hearing an echo, or head pressure (Bayer, 2008). These reactions can cause problems socially in their relationships, school, and/or jobs. Individuals with IED can sometimes suppress their anger, to an extent, and react in a less destructive manner. Signs of impulsivity or aggressiveness may be present between episodes (Bayer, 2008). They may report problems with anger and "sub-threshold" episodes. Individuals with narcissistic, obsessive, paranoid, or schizoid traits may be especially prone to having explosive outbursts of anger when under increased stress.

Child vs. adult presentation

Children may react with a temper, hyperactivity, or destructive actions such as tearing up objects, setting objects on fire, or taking from others. There is no exact age of when IED begins, however it is believed to occur from childhood to late teens or twenties.

Gender and cultural differences in presentation

This episodic violent behavior is more frequent in men than women (Bayer, 2008). One form of aggression, known as amok, is characterized by acute, unrestrained violence, typically associated with amnesia. This is primarily seen southeastern Asia but has also been seen in Canada and the United States. Unlike IED, Amok does not occur frequently but in a single episode.

Epidemiology

Very little is known about the epidemiology of intermittent explosive disorder.

Studies have found that IED may be present in over 5% of the population (Kessler, Coccaro, Fava, Jaeger, Jin & Walters, 2006).

One study found that from 3.4% to 10.4% of patients in a psychiatric facility had IED characteristics at some point in their lives (Grant, Levine, Kim & Potenza, 2005).

There is limited data on age at onset, but it appears to be between childhood and the early twenties (Bayer, 2008). The onset may be abrupt with no prodromal period, and the course varies (Bayer, 2008). The course is chronic in some individuals and episodic in others (Bayer, 2008).

Etiology

Developmental problems or neurological symptoms maybe a cause. There may be an imbalance of serotonin or testosterone levels. However, if a physician believes it is due to physiological problems, it may be diagnosed as a general medical condition instead. It may also be caused at a young age due to exposure in family situations where explosive behavior, verbal, or physical abuse were frequent. Exposure to violence at an early age makes it more probable for them to show the same traits as they mature. A genetic factor may also be the cause, allowing the disorder to be passed down.

Empirically supported treatments

Few controlled studies involving treatments for IED exist. Some patients respond to treatments with certain medications such as anti-convulsion, anti-anxiety, mood regulators, anti-depressants, antipsychotics, beta-blockers, alpha(2)-agonists, or phenytoin. Also, some forms of group therapy, such as anger management, may be helpful. Treatment can include also cognitive behavioral therapy that helps the person identify triggers for outbursts and avoid them.

3. Kleptomania (312.32)

A kleptomaniac is not someone who shoplifts on occasion or who steals because they are in need. Kleptomania is defined as the repeated failure to resist the impulse to steal, even when the item is not taken for personal use or for its monetary value (Bayer, 2000). It involves the desire to steal more than the need for the item (Bayer, 2000). A person with kleptomania feels gratification and relief while he or she steals. After stealing, the person is likely to give away, throw away, hoard, or return the items he or she took (Bayer, 2000). People with this impulse-control disorder realize that stealing is wrong and may feel guilty about their behavior, but they are unable to stop themselves from performing the act.

Kleptomania is not an expression of an emotion, an act of rebellion, or an antisocial gesture (Bayer, 2000). Furthermore, it is not a part of a delusional or hallucinogenic experience (Bayer, 2000). Kleptomaniacs do not usually plan the theft ahead of time, and they rarely steal with help from other people (Bayer, 2000). Comorbid disorders may include mood disorders, eating disorders, and anxiety disorders (Bayer, 2000). Getting caught in the act can cause serious legal, social, and occupational problems for people with this disorder. However, kleptomania may persist for years, regardless of apprehension and conviction (Bayer, 2000).

Unlike ordinary stealing, kleptomania is quite rare. According to the DSM-IV, only about 5% of shoplifters are kleptomaniacs. This disorder afflicts more women than men, unlike intermittent explosive disorder, pathological gambling, and pyromania.

Because it is rare and not well-studied, researchers have not yet agreed upon the most effective treatment for kleptomania (Bayer, 2000). Most people with the disorder are likely to keep it a secret and not seek treatment unless they are caught, due to the shame that they feel (Bayer, 2000). It seems that the most effective treatment usually involves a combination of therapies, including medication, psychotherapy, and behavior modification (Bayer, 2000).

DSM-IV-TR criteria

A. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.

B. Increasing sense tension immediately before committing the theft.

C. Pleasure, gratification, or relief at the time of committing the theft.

D. The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.

E. The stealing is not better accounted for by a conduct disorder, a manic episode, or antisocial personality disorder.

Associated features

Kleptomania is an irresistible impulse to steal, stemming from an emotional disturbance rather than economic need. It is frequently observed in patients who are “chemically dependent” or who also have mood, anxiety, or eating disorders. It is possible that people with kleptomania could also be dealing with major depression, panic attacks, social phobia, anorexia nervosa, bulimia nervosa, substance abuse, and obsessive-compulsive disorder. People with this disorder get a thrill from stealing and randomly have an overwhelming urge to do so. They often feel guilty after committing theft and surreptitiously return the stolen items. If the items, usually of lesser importance, are not returned, they are hoarded, discarded, or given away. In less severe instances of kleptomania, things are borrowed and not returned. Kleptomania is not to be confused with the regular act of stealing. Whether planned or impulsive, a normal thief steals for the objects value or usefulness. Many times they are teenagers or gang members that view theft as a rite of passage, form of rebellion, or commit them just for a dare or for social acceptance; this should not be diagnosed as kleptomania.

Child vs. adult presentation

It is difficult to assess the differences in presentation of kleptomania among children and adults. This is because it is virtually impossible to distinguish if children are stealing because of a disorder or if it is because they do not know any better. Kleptomania typically presents itself during late adolescence or early adulthood. It is rare for kleptomania to manifest itself during a person's early childhood or late in their life.

Gender and cultural differences in presentation

Kleptomania occurs slightly more often in males than in females. No information is available regarding cultural differences in the presentation of kleptomania.

Epidemiology

Studies suggest that approximately 0.6% of the general population that may have this disorder. Studies also suggest that it is more prominent in females. Other studies, interestingly, have found high comorbidity rates (65%) of kleptomania in patients with bulimia. Also, approximately 0.7% of patients also have a history of obsessive-compulsive disorder.

Course

The DSM-IV-TR identifies three courses of kleptomania:

sporadic stealing with brief episodes and long periods of remission

episodic stealing with protracted periods of stealing and periods of remission

chronic stealing, in which the individual steals constantly, with some degree of fluctuation

The disorder may continue for years, despite convictions for shoplifting.

Etiology

One theory suggests that receiving the thrill of stealing can aid in alleviating symptoms in people who are clinically depressed. Individuals with kleptomania never seek aid in the act of theft and never plan to steal with others present. There may be favored objects or environments where thefts occur, but detection of kleptomania, even by family, is difficult. Consequently, the problem mostly goes undetected.

There is no known cause for kleptomania. It is possible that it is genetically related, especially from first-degree relatives. There also tends to be an inclination for kleptomania to coexist with OCD, bulimia nervosa, and clinical depression.

Empirically supported treatments

Actually finding a diagnosis is typically difficult given that patients do not seek medical help for this complaint. It is also difficult to detect during initial psychological assessments. It is most commonly addressed when one comes in for other reasons such as depression, bulimia, or emotional instability. They may prefer certain objects and settings, but these may not be described by the patient. Initial psychological evaluations may reveal a past of inadequate parenting, conflicting relationships, or a point of severe stressors such as having to make a move from one home to another.

Treatments will vary concerning this disorder. It begins with an extensive psychological assessment. The patient then undergoes therapy that targets impulse control and any and all coexisting mental disorders. They gain a comprehensible understanding of their specific triggers in order to prevent relapse. Psychotherapies, such as cognitive-behavioral therapy and rational-emotive therapy, are included in the treatment.

Several medications have been shown to work, but effectiveness depends on other mental disabilities the individual may have. Antidepressants, such as Prozac, are the most commonly used medications to treat kleptomania. These are serotonin re-uptake inhibitors. Side-effects often occur, so patients should consult doctor if any occur. Mood stabilizers can also be used to stabilize the individual's mood. These are meant to keep the patient from having rapid or uneven mood changes that may trigger them to steal. An example of this includes lithium, which is shown to be somewhat helpful. Benzodiazepines can also be used, but the effectiveness often varies from person to person. Individuals may eaisily become dependent on the drug. These medications are central nervous system depressants, also known as tranquilizers. Examples of these include Xanax and Klonopin. Lastly, there are addiction medications such as Revia, an opioid antagonist that is most commonly prescribed for kleptomania. This drug blocks the part of the brain that feels pleasure during certain addictive behaviors, reducing the patient's urge to steal.

4. Pathological Gambling (312.21)

Pathological gambling (PG) involves being unable to resist the impulse to gamble. The transition from recreational gambling to pathological gambling may occur gradually, or it may transition suddenly in response to a stressful event such as job loss (Bayer, 2000).

Some features associated with pathological gamblers include denial, overconfidence, delusions of grandeur, development of superstitions, highly competitive, and overly concerned with approval from others (Bayer, 2000). In order to be diagnosed as a pathological gambler, the individuals symptoms must be persistent and recurrent, and the individual must be preoccupied with reliving past gambling experiences or planning future gambling excursions (Bayer, 2000). After some time, the individual may feel compelled to take higher risks to produce the desired level of excitement. This disorder can result in a host of occupational, social, and legal problems. Compulsive gamblers often find themselves lying to their family members and friends to hide the severity of their problem. They may even resort to illegal, but typically nonviolent, means of acquiring money to gamble (Bayer, 2000).

Compulsive gamblers are more prone to medical conditions that are brought about by stress such as hypertension, peptic ulcers, and migraine headaches (Bayer, 2000). They may also have comorbid mood disorders, substance-related disorders, antisocial behavior, attention-deficit disorder, or hyperactivity (Bayer, 2000). Compulsive gambling can be confused with bipolar disorder, which sometimes accompanies compulsive gambling (Bayer, 2000).

This impulse-control disorder is more common among men than women. Women who do have this disorder are often hesitant to seek treatment; this may be because society tends to view gambling as less acceptable for women than men.

Pathological gambling typically begins in adolescence for boys and later in life for girls (Bayer, 2000). It may be regular or episodic, but it is often chronic (Bayer, 2000). Environmental stressors or depression may increase the frequency of gambling (Bayer, 2000).

(4) is restless or irritable when attempting to cut down or stop gambling

(5) gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)

(6) after losing money gambling, often returns another day to get even ("chasing" one's losses)

(7) lies to family members, therapist, or others to conceal the extent of involvement with gambling

(8) has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling

(9) has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling

(10) relies on others to provide money to relieve a desperate financial situation caused by gambling

B. The gambling behavior is not better accounted for by a manic episode.

Associated features

Pathological gambling (PG) is characterized as a chronic, progressively maladaptive, impulse-control disorder, that is distinguished by continued acts of gambling despite compounding severe negative consequences. Individuals with PG may present distortions in thinking and may believe that money is both the cause and solution to all of their problems. Individuals with PG tend to be highly competitive, energetic, and easily bored. They may be overly concerned with others' approval and may be extravagantly generous. When they are not gambling, they may considered to be workaholics or "binge" workers. They may be at risk for medical conditions associated with stress, and those seeking treatment have high rates of suicidal ideation and attempts. Individuals who suffer from PG often have problematic interpersonal relationships. These relationships become increasingly strained during the progression of the disorder. Some individuals with PG may try to legally finance gambling and living expenses through loans. Others may also commit illegal acts such as forgery, fraud, theft, or embezzlement in order to gain financing. There is evidence to support comorbidity of PG with alcohol abuse and depression. A 1992 study showed that 12.9% of heavy drinkers had a gambling problem, compared to 5% of nondrinkers. Comorbidity rates of PG and major depressive disorder can reach as high as 76%. Other associated features of PG include unemployment, substance abuse, and suicide attempts. Most pathological gamblers tend to deny their problem and therefore do not get help. Associated features also include repetitive behaviors which shares features with obsessive-compulsive disorder.

Child vs. adult presentation

Historically, PG has been stereotyped as an adult disorder, but with the vast growth of casino expansion and the creation of internet gambling, adolescent rates of PG have superseded adult prevalence rates by two to four times. According to a 2006 Adolescent Psychiatry article by Timothy W. Fong, gambling is a media-driven, socially acceptable form of behavior. Fong also noted that 86% to 93% of all adolescents have gambled for money at least once (2006). Seventy-five percent of those did it within the confines of their home, while 85% of parents did not care (Fong, 2006). Fong stated that adolescent gambling is the most popular risk-taking behavior seen in adolescents, trumping cigarettes, alcohol, drugs, and sex (2006). The reasons why adolescents start gambling in comparison to the reasons why adults start gambling are very different. Adolescents use gambling as a form of excitement, a relief of boredom, and a coping mechanism or relief from daily stress. Adolescents have a need to keep playing for spectator success, and gambling is a social acceptable form of competition.

Gender and cultural differences in presentation

More men than women are diagnosed with pathological gambling, with a 2:1 ratio, and men have a higher tendency to start at a younger age. Gambling usually begins in early adolescence in men and from ages 20-40 in women. Culturally, pathological gambling is more prevalent in minority groups. Socioeconomic status also strongly correlates; it is more common in poor individuals who cannot afford to gamble and who inevitably feel as though they cannot afford not to gamble.

Epidemiology

As gambling facilities become more prevalent, so do PG rates. In fact, 2 million Americans are considered to be pathological gamblers, with another 3 million considered being “problematic gamblers,” and 15 million more considered to be at risk. There is a 4% prevalence rate in America. Prevalence rates in other countries vary. Worldwide rates range from 2% to 6%.

Pathological gambling usually begins in early adolescence in males and later in life in females. A few individuals are "hooked" with their first bet, but for most the course is more insidious. Years of social gambling may be followed by an abrupt onset that may be precipitated by greater exposure to gambling or to some stressor. The pattern may be regular or episodic, and the course of the disorder is often chronic.

Etiology

The causes do not seem to be biological as there is no evidence to support it. A psychological cause is more likely. A pathological gambler typically has symptoms of depression or alcoholic tendencies. They usually turn to gambling to get the “high” of winning to escape from everyday problems or more serious life problems.

Empirically supported treatments

Treatment for PG includes therapy and possibly medication. Before treatment can begin, the individual must first realize that they do indeed have a problem and that they need help. Announcing this to friends and family is usually best. Treatment is based on behavior changes. The counselor will usually start by uncovering the underlying cause of the gambling addiction. If the patient is depressed then the depression is treated accordingly. For several of the people who stay in treatment, it is successful. On average, however, 50% drop out of the therapy.

Aversion therapy is one option available to pathological gamblers. During aversion therapy, the patient is exposed to the stimulus while also being exposed to something that would cause them discomfort. Treatments usually try to help the patient overcome their impulses and learn to control urges. Also, the gambler must learn to overcome the illusion that they will “win the next time.”

There are also self-help groups like Gamblers Anonymous that the patient can join. Groups for the family are also available.

It is often recommended that the individual never return to gambling. It is also recommended that the individual never return to the places that he or she gambled, because returning causes the patient to be at high risk for a relapse.

Medications such as antidepressants and opioid antagonists (naltrexone) may help, also.

5. Pyromania (312.33)

Pyromania is characterized by multiple deliberate attempts at fire setting that can provide the individual with psychological gratification and relief (Bayer, 2000). The diagnosis of pyromania does not apply if a person sets fire because he or she is mentally retarded, intoxicated, or has impaired judgment due to a medical condition (Bayer, 2000). An individual is not diagnosed with pyromania if he or she sets fire because of some other psychological disorder (Bayer, 2000). People with pyromania do not set fires to express their emotions, to make money, or to support a political ideology (Bayer, 2000). Their intention is not to destroy evidence of criminal activity or to improve their living situation (Bayer, 2000). Additionally, their fire setting is not a response to a delusion or hallucination (Bayer, 2000).

People with pyromania are fascinated by fire and may be attracted to fire-related equipment such as fire trucks, hoses, and hydrants (Bayer, 2000). They may deliberately seek to observe fires, set false alarms, or associate with fire departments or firefighters (Bayer, 2000). They may spend a great deal of time preparing to set fires (Bayer, 2000). They may be indifferent to the loss of life and property that the fires cause (Bayer, 2000). They may even derive pleasure from thinking about the destruction, danger, and consequences of the fires (Bayer, 2000). Since the individual often derives pleasure from being near fires and the results, he or she often stays in the vicinity of the scene after a fire has been set (Bayer, 2000).

This impulse-control disorder is somewhat rare. Pyromania typically begins in childhood. Males are diagnosed more often than females, particularly males with poor social skills and learning difficulties (Bayer, 2000). The course of the disorder may wax and wane (Bayer, 2000). The disorder often lasts only a few years or during a specific period of an individual's life (Bayer, 2000). Often, it initially appears during a crisis and disappears after the crisis has dissolved (Bayer, 2000).

Fire Play Versus Fire Setting:

Fire Play (childhood experimentation)

Fire setting (pyromaniac behavior)

1. The incident occurred only once.

1. The behavior has recurred.

2. The action was unplanned.

2. The action was planned.

3. The individual burned paper, trash, or leaves.

3. The individual used flammable or combustible material to ignite property of some value.

4. The individual burned garbage or his or her own property.

4. The individual burned someone else's property, an animal, or a person.

D. The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one’s living circumstances, in response to a delusion or a hallucination, or as a result of impaired judgment (e.g., in dementia, mental retardation, substance intoxication).

E. The fire setting is not motivated by monetary gain, sociopolitical ideology, anger or revenge, psychotic thinking (delusions or hallucinations), or to conceal criminal activity.

The fire setting is not better accounted for by conduct disorder, a manic episode, or antisocial personality disorder.

Associated features

Individuals with pyromania often have a difficult time controlling themselves, specifically in situations that are harmful to themselves and others. They may make considerable advance preparation for starting a fire, and may be indifferent to the consequences of their actions. They may derive pleasure from the resulting destruction. Those with head injuries or epilepsy are at an increased risk of developing and impulse control disorder. Researchers have noticed an increase in impulse-control disorders in older patients with Parkinson’s disease due to the effect of the dopaminergic drugs. There has also been a correlation with pyromania and learning disabilities and cruelty to animals.

Child vs. adult presentation

The age of onset for pyromania is approximately 18 years of age. It is extremely rare for a child younger than adolescence to develop pyromania. It is also rare for an older adult to develop the disorder. Those older than adolescence tend to develop primarily pathological gambling.

It is rare for children to have it, but it can occur in children as young as three years old. Most of the time, parents recognize the behaviors and get it treated before it becomes a problem.

Gender and cultural differences in presentation

Males have a much higher risk for developing pyromania than females. Approximately 90% of those diagnosed with pyromania are male. There are no cultural differences in the presentation of this disorder. People from many different cultures show the same symptoms.

Epidemiology

It is a very rare disorder, with less than 1% of the population meeting the diagnostic criteria.

Most of the research done on pyromania has not focused on the epidemiology. It is only known that there is a higher prevalence of pyromania in men than women.

It is known that about 9% of the population have impulse-control problems that include pyromania.

Only 14% of fires are started by people with pyromania and other mental disorders.

Etiology

Although little research has been done on the etiology of pyromania, it is believed that the cause can be targeted during childhood. Many researchers say that possible causes can be an abusive family environment or mild brain trauma.

Some suggest that pyromania may be a form of communication from those that have few social skills.

Empirically supported treatments

Counseling and medication are both preferred for treating pyromania. So far, behavior modification has been found to be the best treatment this disorder.

Treatment of adults and children with pyromania is often individualized based on the patient’s presenting problems and history. Treatment of children with this disorder often begins with an assessment of the child’s life and includes the evaluation of such factors as stressors on the child, home discipline, and supervision of the child. This assessment is generally followed by a case-management approach, rather than a medicinal approach, where the treatment is tailored to the child and involves a variety of approaches, such as anger management and communication skills.

Treatment of adults with pyromania is often approached differently. Because adult patients with this disorder tend to be uncooperative, they are generally treated with a combination of medication and psychotherapy. Usually the patient is treated with a selective serotonin reuptake inhibitor (SSRI), but there have also been multiple case reports of tricyclic antidepressants and monamine oxidase inhibitors (MAIOs) being useful in impulse control disorders.

6. Trichotillomania (312.39)

Trichotillomania, also known as trich, is a poorly understood disorder characterized by the recurrent pulling out of one's own hair that results in noticeable hair loss (Chamberlain, Menzies, Sahakian & Fineberg, 2007). A person with trichotillomania may pull out hair from any part of his or her body. The most common locations pulled are the scalp, eyebrows, and eyelashes. For people who suffer from this impulse-control disorder, pulling decreases stress and tension and causes pleasure (Bayer, 2000). The pulling may occur during periods of relaxation. However, stressful events tend to increase the amount of time a person may spend pulling his or her hair (Bayer, 2000). The act of pulling may take place in brief episodes throughout the day or during less-frequent periods that can last for hours (Bayer, 2000).

Trichotillomania causes considerable social and occupational problems. Sufferers do not typically pull their hair in front of others unless they are close family members, so they may tend to avoid social situations (Bayer, 2000). Some people with trichotillomania may deny the behavior and attempt to conceal bald spots (Bayer, 2000).

Some researchers suggest that trich is a compulsive behavior. Although people who seek treatment for trich may do so for reasons similar to people with OCD, trich is different from OCD in several ways. Unlike OCD, the behavior is not performed in response to an obsessional thought or to prevent some unwanted event or situation (Bayer, 2000). Furthermore, individuals with trich only pull hair, whereas people with OCD may perform multiple types of rituals (Bayer, 2000). Also, while OCD is equally evident in males and females, trich is a predominately a female disorder (Bayer, 2000).

Trichotillomania usually begins in childhood, but short term episodes of hair pulling in childhood may be a benign habit that does not persist later in life (Bayer, 2000). Some individuals experience continuous symptoms for several years while others can go into remission for weeks, months, or years (Bayer, 2000). High amounts stress may cause the behavior to reappear (Bayer, 2000). Those who suffer from trichotillomania are more likely than the general population to have mood, anxiety, and substance-related disorders (Bayer, 2000). According to DSM-IV, 1-2% of college students have a current or past history of the illness.

B. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior.

C. Pleasure, gratification, or relief when pulling out the hair.

D. The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition.)

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Associated Features

Individuals with trichotillomania are often seen by the public as having a habit of playing with their hair. People with trich will examine the hair root, twirl it off, pull the strand of hair between their teeth, or may eat their hair. Hair eating is known as trichophagia. They usually do not pull their hair out in the presence of anyone except family members. Some individuals suffering from this disorder will deny that they pull out their hair and will attempt to hide the resulting baldness. If the case is extreme, the individual may have urges to pull other people's hair, but often can refrain. Dolls, pets, carpet, and sweaters are often pulled on like hair (Bayer, 2008). Nail biting, scratching, gnawing, and excoriation (tearing off skin or skin picking) are often associated with this disorder.

Trichotillomania is linked to obsessive-compulsive disorder; often, both disorders are present in younger females. The pulling of the hair becomes a habit to obsess about. Many of the same attributes of OCD appear in patient with trichotillomania including the need for perfection and order. Hair pulling has appeared to be stress relief from the obsessions.

Child vs. Adult presentation

Trich usually begins in late childhood or early adolescence. The peak age of onset is 13 to 14 years old (Chamberlain et al., 2007). It is more common during the first 20 years of someone's life. There is not a difference in presentation between children and adults, however. Children with trich may feel socially isolated because they often feel that no one else has this disorder (Anegundi, Shetty, Yavagal & Pandurangi, 2010)

Gender and cultural differences in presentation

When presented in children, the rates between genders tend to be relatively equal. However, trichotillomania is more common in adult females than adult males. It has been found that approximately 70% of adults that have trich are female (Anegundi et al., 2010). This finding of an off-balance male-to-female ratio may be a result of the true gender ratio of the condition, or it could be due to treatment-seeking curve formed due to cultural or gender based attitudes regarding acceptance of the associated features of this disease (Anegundi, Shetty, Yavagal & Pandurangi, 2010).

Women tend to pull from limited locations while men pull from many locations on the body (Anegundi et al., 2010)

Epidemiology

Trichotillomania is now believed to be more common than it once was. Studies show that today the lifetime prevalence rate of this disorder is 0.6%, but it is difficult to determine. This rate is based on the psychological affect- the release of tension after pulling the hair out. However, when including those individuals who subconsciously pull hair, the rate is approximately 1.5% for males and 3.4% of females. A study of 2,500 college students found similar lifetime prevalence rates when using strict DSM-III-R criteria (Chamberlain et al., 2007).

Trich is often comorbid with with mood and anxiety disorders, such as major depression, generalized anxiety disorder, and simple phobias (Chamberlain et al., 2007).

Etiology

There is evidence of a genetic predisposition. Hair pulling and similar grooming phenomena often occur in family members of people with trich (Chamberlain et al., 2007). Mutations in a gene called SLITRK1 have been linked to trichotillomania as well as to Tourette syndrome, a neurological disorder that causes a person to make unusual movements and sounds.

Neurochemical problems can also play a role in trichotillomania. Some studies suggest that abnormalities in the natural brain chemicals serotonin and dopamine may play a role.

There are two types of trichotillomania that have been described: focused pulling and non-focused pulling. The focused pulling is used to control negative emotions, such as anger. The non-focused pulling is a nonintentional type of pulling that occurs without the patients complete awareness.

Empirically supported treatments

Treatment for trichotillomania may be through behavior therapy aimed at habit reversal (Chamberlain et al., 2007). Sufferers learn to identify when they have urges to pull out their hair and how to relax in order to reduce the tension caused by the urge. Therapy also helps them develop a competing response when their urge arises. For example, they may make a fist with their hands to stop from pulling out hair.

Cognitive therapy may also be used to address distorted thinking.

Medication such as an antidepressant called selective serotonin reuptake inhibitors (SSRIs) may be used as part of the treatment program as well.

Given the limited amount of research available, no formal treatment algorithm can be created (Chamberlain et al., 2007)

7. Impulse-Control Disorder NOS (312.30)

*Associated Features
***Individuals who fall under Impulse-Control Disorder NOS do not meet any of the criteria for the above disorders or any of the other impulse control disorders in the DSM-IV-TR. (eg. substance abuse, paraphilias). Some common impulse-control disorders in this category include impulsive sexual behaviors, pathological skin picking, self-mutilation, and compulsive shopping. Those with sexual impulses often are promiscuous, show compulsive masturbation, show a compulsive use phone sex lines and/or pornography, and often show pornography dependence. Compulsive shopping problems appear more in women than men. It is often associated with the individual's need to control his or her mood, which the person does by compulsively buying things and spending money. Pathological skin pickers may pick pimples and scabs on the face or anywhere else on the body (Spiegel & Finklea, 2009). Like trichotillomania, SSRIs are typically used as treatment for this disorder (Spiegel & Finklea, 2009).

Etiology

Impulsive behavior seems to have an underlying pre-disposition which may or may not be related to existing mental health or medical conditions, but research over the past decade has stressed the substantial co-morbidity of impulse control disorders with mood disorders, anxiety disorders, eating disorders, substance abuse, personality disorders, and with other specific impulse control disorders. In particular cases, it may be clinically difficult to disentangle from one another, with the result that the impulsivity at the core of the disorders is obscured.

Empirically supported Treatments

Although the specific category of impulse control disorders has become firmly entrenched in the DSM-IV-TR, strictly defined cases are nonetheless relatively uncommon with the result that there have not been many large scale studies of homogeneous populations. Clinicians widely appreciate, however, that these behavioral problems can cause significant stress for individuals and their families and justify further study and attempts at treatment. Findings in recent research have led some researchers to suggest that impulse control disorders form part of “the affective spectrum” linked by some common neurochemical abnormality involving low brain serotonin levels. This interest in a possible neurochemical basis for impulsive behaviors leads clinicians to hope that newer pharmacological therapies may be soon available. As well, advances in cognitive behavioral treatment suggest that a combination of pharmacotherapy and cognitive behavioral treatment may mutually enhance each other’s benefits.

8. ICDs versus OCD

The entire group of impulse-control disorders have never been assessed in a large, population-based sample; therefore, the extent to which they form a cohesive group and to which they fit into an empirically supported structure of psychiatric disorders cannot be directly examined (Potenza, Koran & Pallanti, 2009).

Some impulse-control disorders, specifically intermittent explosive disorder and pathological gambling, share features with obsessive-compulsive disorder, suggesting that these disorders may be categorized together. However, available data suggests significant differences between the disorders. For example, outbursts in IED are unplanned and, unlike OCD, do not occur in response to an obsession (Potenza et al., 2009). Also, IED is more common in men than women by a 2:1 male-to-female ratio, whereas OCD is often found to be equally as common or slightly predominant in females (Potenza et al., 2009).

OCD is characterized by ego-dystonic behaviors while pathological gambling is characterized by ego-syntonic or hedonic behaviors (Potenza et al., 2009). The pleasure derived from gambling may diminish over time, which is similar to substance dependence (Potenza et al., 2009).

9. Impulse-Control Disorders in College Students

A study of 571 college students, ranging from 17 to 48 years of age, found that 3.5% of participants met the criteria for at least one ICD diagnosis (Bohne, 2010). Based on a questionnaire screening, 1.2% met the criteria for pyromania, 0.9% for intermittent explosive disorder, 0.9% for kleptomania, and 0.4% for pathological gambling (Bohne, 2010). Eighty percent of the participants that positively screened for an impulse control disorder were male (Bohne, 2010).